Post-Cerclage Monitoring
Routine serial ultrasound monitoring after cerclage placement is NOT recommended, as insufficient evidence supports clinical benefit. 1, 2
Immediate Post-Procedure Management
Progesterone Supplementation
- Add vaginal progesterone 200 mg daily after cerclage placement, which significantly reduces spontaneous preterm birth at <34 weeks (2.2% vs 18.4%) and <37 weeks (9.1% vs 29.7%) compared to cerclage alone. 1, 2, 3
- Continue progesterone through the pregnancy regardless of cervical stability. 3
Activity and Symptom Monitoring
- Counsel patients to report signs of preterm labor (contractions, pelvic pressure, vaginal bleeding or fluid leakage). 4
- Monitor for signs of infection including fever, uterine tenderness, or purulent vaginal discharge. 4
Surveillance Strategy
Ultrasound Monitoring
- Do NOT perform routine serial ultrasound cervical length assessments after history-indicated cerclage, as evidence does not demonstrate clinical benefit despite associations between shorter cervical length below cerclage and higher preterm birth rates. 1, 2
- If ultrasound is performed for other clinical indications, measure the total length of closed cervix regardless of sutures; when funneling is present, measure from the level of funneling to the cerclage sutures. 2
When to Consider Ultrasound Assessment
- Reserve ultrasound evaluation for patients with concerning symptoms (new pelvic pressure, vaginal discharge changes, bleeding). 2
- In cases of documented progressive cervical shortening despite progesterone, frequent ultrasonographic follow-up may be prudent, though optimal frequency lacks high-quality evidence. 3
Infection Screening
- Obtain urinalysis with culture and sensitivity plus vaginal cultures for bacterial vaginosis at the first obstetric visit after cerclage. 5
- Treat any identified infections promptly. 5
Critical Pitfalls to Avoid
- Do not routinely monitor cervical length by ultrasound after history-indicated cerclage—this represents unnecessary surveillance without proven benefit. 1, 2
- Do not withhold vaginal progesterone supplementation, as this represents the single most important adjunctive therapy after cerclage. 1, 2, 3
- Avoid using 17-alpha hydroxyprogesterone caproate (17-OHPC) instead of vaginal progesterone, as guidelines recommend against this agent. 2
- Do not place cervical pessary due to conflicting data and recent safety signals including increased perinatal mortality. 2
Management of Cerclage After PPROM
If preterm prelabor rupture of membranes (PPROM) occurs with cerclage in place, either removing the cerclage or leaving it in situ are reasonable options after discussing risks and benefits through shared decision-making. 4